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You have been asked to see Mrs. D. Pressed. She is a 78 year old woman whose husband died suddenly of a heart attack one month ago.

Her family doctor reports that since the death, she has appeared sad-looking, with low energy and trouble falling asleep. She has spoken of “feeling his presence” and hearing his voice call her name. She is accompanied by one of her daughters.

You recently received a tool on depression assessment for older adults from NICE, or National Institute for the Care of the Elderly. After reviewing it, you decide to take it with you as it may be helpful in assessing Mrs. Pressed.

She feels “down” with poor sleep and energy, and hasn’t been enjoying usual activities like knitting or playing bridge with friends. Her appetite and concentration are normal, and she denies hopelessness or suicidal ideation.

She sometimes hears her husband’s voice calling her name, but knows he has died. She does not report symptoms of anxiety or psychosis. She has not been drinking alcohol. There is no impairment in cognition or functioning.

Mrs. Pressed was born in Windsor, NS. Her childhood was unremarkable. She finished Grade 10 and then worked as a waitress. She married at age 18 and moved to Halifax with her husband. She stayed at home to raise their three daughters, and then worked as the church secretary for 15 years until she retired at age 60. Her husband retired from his job at the bank at age 65. They moved into a seniors’ apartment five years ago, and usually spend the winter in Florida. Only one of her daughters still lives in Halifax.

Mrs. Pressed does not attend her follow-up appointment. Two months later you see her in the emergency department after she has taken an overdose of Gravol. She has significantly deteriorated and rarely gets out of bed. She stopped eating and drinking one week ago and has lost 20 pounds. She rarely bathes, and doesn’t clean the house. She is very quiet, but often speaks of having headaches. She believes this is from “brain cancer”, and that she is dying. She wishes she had died from the overdose.

Mrs. Pressed is admitted to an acute care ward for treatment of psychotic depression. You meet with her daughter to discuss treatment options. Before discussing treatment, her daughter requests education on depression in the elderly. She asks, “Isn’t it normal to be sad when you’re old? Why does she need treatment?”

You start Mrs. Pressed on Citalopram 5 mg, in one week increasing the dose to 10 mg. By one month she is taking 20 mg OD and starting to feel better. Her daughter calls 2 weeks later to say her mother seems very confused and disoriented. You suggest she sees the family doctor to check for hyponatremia, which is found on blood work.

Citalopram is reduced to 10 mg, the hyponatremia resolves, but her mood deteriorates on the lower dose. After 6 weeks with normal blood work, you suggest she increase the dose back to 20 mg, and you monitor electrolytes closely.

In 2 months she is feeling 70% better, but is still not enjoying her previous hobbies, such as knitting or playing bridge. She still misses her husband terribly. She is also worried about taking any more medication.

Given Mrs. Pressed’s concern about increasing the dose of medication, you decide together to pursue a non-pharmacological augmentation treatment. She attends a grief group at the hospital day program for 10 weeks. When seen three months later, she is doing well.

You continue to follow up with Mrs. Pressed for another 2 years and she does very well. With your expert skills (and some luck) she does not have a relapse. Hopefully your involvement in this case has helped you become more familiar with the Depression & Suicide National Guidelines of the CCSMH.